Publications by authors named "Peter J Winch"

169 Publications

Determinants of intermittent preventive treatment with sulfadoxine-pyrimethamine in pregnant women (IPTp-SP) in Mali, a household survey.

Malar J 2021 May 22;20(1):231. Epub 2021 May 22.

Department of Education and Research in Public Health and Specialties, Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.

Background: In malaria endemic regions, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women during prenatal consultation, from the fourth month of pregnancy up to the time of delivery. The Government of Mali is aiming for universal coverage of IPTp-SP. However, coverage is still low, estimated to be 18% for completion of three doses (IPTp-SP3). The objective of this study was to identify the factors that influence IPTp-SP adherence in the Health District of Sélingué, Mali.

Methods: This was a cross-sectional survey with 30 clusters, proportional to village size, with two stages of sampling. Data were collected electronically with Magpi software during face-to-face interviews/surveys. The data were analysed with SPSS version 20. A descriptive analysis and bivariate and multivariate logistic regression were performed. An equity analysis examined the effect of distance from health care facility on completion of three or more antenatal visits (ANC3 +) and three or more doses of intermittent preventive treatment (IPTp-SP3 +).

Results: Of the 1,021 women surveyed, 87.8% (n = 896) attended at least one ANC visit. Of these, 86.3% (n = 773) received at least one dose of IPTp-SP. Compliance with three or more doses of IPTp-SP was 63.7%. The determinants statistically related to ANC3 + were the early initiation of ANC (OR = 3.22 [1.22, 10.78]), and the presence of a community health centre (CHC) in the village (OR = 9.69 [1.09, 86.21]). The ability to read (OR = 1.60 [1.01, 2.55]), the early initiation of ANC (OR = 1.46 [1.06, 2.00], knowledge of the utility of the drug (OR = 2.38 [1.24, 4.57]), and knowledge of the recommended dose of the drug (OR = 6.11 [3.98, 9.39]) were related to completion of three or more treatments (IPTp-SP3 +).

Conclusion: The early initiation of ANC was a positive determinant of the completeness of both ANC3 + and IPTp-SP3 + . This study shows that a successful implementation of the IPTp strategy can be achieved by improving access to prenatal care at community health facilities, and strengthening patient-provider communication to ensure adequate knowledge on dosing of IPTp-SP and the benefits to mother and child.
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http://dx.doi.org/10.1186/s12936-021-03764-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141251PMC
May 2021

Between the City and the Farm: Food Environments in Artisanal Mining Communities in Upper Guinea.

Public Health Nutr 2021 May 12:1-34. Epub 2021 May 12.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, USA.

Objective: Artisanal and small-scale mining (ASM) is a widespread livelihood in low- and middle-income countries, however many in ASM communities face high levels of poverty and malnutrition. The food environments in ASM communities have non-agricultural rural characteristics that differ from those in urban and subsistence rural areas examined in much existing food environment literature.

Design: We examine these complex external and personal food environments in ASM communities via a study using qualitative and quantitative methods. Market surveys and a cross-sectional household survey, plus qualitative mining site non-participant observations and in-depth structured interviews, were conducted in three waves.

Setting: Eighteen study sites in ASM communities in northern Guinea.

Participants: Surveys covered mothers in mining households with young children (n=613); in-depth interviews engaged mothers of young children (n=45), food vendors (n=40), and young single miners (n=15); observations focused on mothers of young children (n=25).

Results: The external food environment in these ASM communities combines widespread availability of commercially-processed and staple-heavy foods with lower availability and higher prices for more nutritious, non-staple foods. Within the personal food environment, miners are constrained in their food choices by considerable variability in daily cash income and limited time for acquisition and preparation.

Conclusions: We demonstrate that ASM communities have characteristics of both urban and rural populations and argue for greater nuance and appreciation of complexity in food environment research and resultant policy and programming.
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http://dx.doi.org/10.1017/S1368980021002020DOI Listing
May 2021

Making the invisible visible: Developing and evaluating an intervention to raise awareness and reduce lead exposure among children and their caregivers in rural Bangladesh.

Environ Res 2021 Aug 7;199:111292. Epub 2021 May 7.

Stanford University, Stanford, CA, USA. Electronic address:

Lead exposure is harmful at any time in life, but pre-natal and early childhood exposures are particularly detrimental to cognitive development. In Bangladesh, multiple household-level lead exposures pose risks, including turmeric adulterated with lead chromate and food storage in lead-soldered cans. We developed and evaluated an intervention to reduce lead exposure among children and their caregivers in rural Bangladesh. We conducted formative research to inform theory-based behavioral recommendations. Lead exposure was one of several topics covered in the multi-component intervention focused on early child development. Community health workers (CHWs) delivered the lead component of the intervention during group sessions with pregnant women and mother-child dyads (<15 months old) in a cluster-randomized trial. We administered household surveys at baseline (control n = 301; intervention n = 320) and 9 months later at endline (control n = 279; intervention n = 239) and calculated adjusted risk and mean differences for primary outcomes. We conducted two qualitative assessments, one after 3 months and a second after 9 months, to examine the feasibility and benefits of the intervention. At endline, the prevalence of lead awareness was 52 percentage points higher in the intervention arm compared to the control (adjusted risk difference: 0.52 [95% CI 0.46 to 0.61]). Safe turmeric consumption and food storage practices were more common in the intervention versus control arm at endline, with adjusted risk differences of 0.22 [0.10 to 0.32] and 0.13 [0.00 to 0.19], respectively. Semi-structured interviews conducted with a subset of participants after the intervention revealed that the perceived benefit of reducing lead exposure was high because of the long-term negative impacts that lead can have on child cognitive development. The study demonstrates that a group-based CHW-led intervention can effectively raise awareness about and motivate lead exposure prevention behaviors in rural Bangladesh. Future efforts should combine similar awareness-raising efforts with longer-term regulatory and structural changes to systematically and sustainably reduce lead exposure.
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http://dx.doi.org/10.1016/j.envres.2021.111292DOI Listing
August 2021

The Lived Experiences of Community Health Workers Serving in a Large-Scale Water, Sanitation, and Hygiene Intervention Trial in Rural Bangladesh.

Int J Environ Res Public Health 2021 03 25;18(7). Epub 2021 Mar 25.

Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.

Community health workers (CHWs) are key to implementing community-based health interventions and quality can be enhanced by better understanding their lived experiences. The WASH Benefits, Bangladesh trial engaged 540 female CHWs to promote varying health intervention packages. We report on factors influencing their lived experiences during the trial, to aid future recruitment, training and retention of CHWs. Nine focus groups and 18 in-depth interviews were conducted with CHWs. Focus groups and interviews were transcribed and thematic content analysis performed to summarize the results. All CHWs described experiencing positive working conditions and many benefits both socially and financially; these contributed to their retention and job satisfaction. Their honorarium was commonly applied towards their children's education and invested for income generation. CHWs gained self-confidence as women, to move unaccompanied in the community and speak in public. They earned respect from the community and their family members who helped them manage their family obligations during work and were viewed as a resource for advice on health and social issues. Many participated in family decision-making from which they were previously excluded. Health programs should foster a positive experience among their CHWs to aid the recruitment, retention and development of this important human resource.
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http://dx.doi.org/10.3390/ijerph18073389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037636PMC
March 2021

"If you don't find anything, you can't eat" - Mining livelihoods and income, gender roles, and food choices in northern Guinea.

Resour Policy 2021 Mar;70:101939

Department of International Health, Johns Hopkins Bloomberg School of Public Health - 615 N Wolfe St, Baltimore, MD, 21205, USA.

Artisanal and small-scale mining (ASM) continues to grow as a viable economic activity in sub-Saharan Africa. The health and environmental impacts of the industry, notably linked to the use of potentially toxic chemicals, has been well documented. What has not been explored to the same extent is how pressures associated with ASM affect food choices of individuals and families living in mining camps. This paper presents research conducted in 18 mining sites in northern Guinea exploring food choices and the various factors affecting food decision-making practices. Two of the most influential factors to emerge from this study are income variability and gender roles. Results from this study suggest that through artisanal mining, women have the opportunity to earn a larger income that would otherwise be unavailable through agriculture. However, this benefit of potentially earning a larger income is often reduced or constrained by existing gender roles both at the mines and in the home, such as disparity in pay between men and women and increased pressures on women's time. This limits the potential benefit to household food decision-making that could have been gained from higher income. These results do not seek to establish one livelihood as superior; rather, they demonstrate that even when presented with opportunities to earn higher incomes, women still face many of the same barriers and challenges that they would in other economic activities. Additionally, while work and time demands on women change upon arrival in the mining camps, existing gender roles and expectations do not, further restricting women's decision-making capacity.
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http://dx.doi.org/10.1016/j.resourpol.2020.101939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7976851PMC
March 2021

A holistic approach to promoting early child development: a cluster randomised trial of a group-based, multicomponent intervention in rural Bangladesh.

BMJ Glob Health 2021 03;6(3)

Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA.

Introduction: In low- and middle-income countries, children experience multiple risks for delayed development. We evaluated a multicomponent, group-based early child development intervention including behavioural recommendations on responsive stimulation, nutrition, water, sanitation, hygiene, mental health and lead exposure prevention.

Methods: We conducted a 9-month, parallel, multiarm, cluster-randomised controlled trial in 31 rural villages in Kishoreganj District, Bangladesh. Villages were randomly allocated to: group sessions ('group'); alternating groups and home visits ('combined'); or a passive control arm. Sessions were delivered fortnightly by trained community members. The primary outcome was child stimulation (Family Care Indicators); the secondary outcome was child development (Ages and Stages Questionnaire Inventory, ASQi). Other outcomes included dietary diversity, latrine status, use of a child potty, handwashing infrastructure, caregiver mental health and knowledge of lead. Analyses were intention to treat. Data collectors were independent from implementers.

Results: In July-August 2017, 621 pregnant women and primary caregivers of children<15 months were enrolled (group n=160, combined n=160, control n=301). At endline, immediately following intervention completion (July-August 2018), 574 participants were assessed (group n=144, combined n=149, control n=281). Primary caregivers in both intervention arms participated in more play activities than control caregivers (age-adjusted means: group 4.22, 95% CI 3.97 to 4.47; combined 4.77, 4.60 to 4.96; control 3.24, 3.05 to 3.39), and provided a larger variety of play materials (age-adjusted means: group 3.63, 3.31 to 3.96; combined 3.81, 3.62 to 3.99; control 2.48, 2.34 to 2.59). Compared with the control arm, children in the group arm had higher total ASQi scores (adjusted mean difference in standardised scores: 0.39, 0.15 to 0.64), while in the combined arm scores were not significantly different from the control (0.25, -0.07 to 0.54).

Conclusion: Our findings suggest that group-based, multicomponent interventions can be effective at improving child development outcomes in rural Bangladesh, and that they have the potential to be delivered at scale.

Trial Registration Number: The trial is registered in ISRCTN (ISRCTN16001234).
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http://dx.doi.org/10.1136/bmjgh-2020-004307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970287PMC
March 2021

Exploration of Attendance, Active Participation, and Behavior Change in a Group-Based Responsive Stimulation, Maternal and Child Health, and Nutrition Intervention.

Am J Trop Med Hyg 2021 Jan 18. Epub 2021 Jan 18.

1Environmental Interventions Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh.

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant's attendance were identified, and the resulting intervention shows promise for future implementation at scale.
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http://dx.doi.org/10.4269/ajtmh.20-0991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045643PMC
January 2021

Could Alcohol-Based Hand Sanitizer Be an Option for Hand Hygiene for Households in Rural Bangladesh?

Am J Trop Med Hyg 2021 Jan 18. Epub 2021 Jan 18.

1International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh.

In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.
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http://dx.doi.org/10.4269/ajtmh.20-0755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941831PMC
January 2021

A scoping review of interventions targeting small-scale, individual-initiated burning practices.

Environ Res 2021 04 27;195:110794. Epub 2021 Jan 27.

Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.

Background: Ambient outdoor air pollution has been identified as a key risk factor for adverse health outcomes and mortality, particularly in low- and middle-income countries (LMICs). Small-scale, individual-initiated burning activities are significant contributors to local pollutant emissions but are not well studied. We identified articles that describe small-scale burning interventions in order to characterize current trends, implementation science perspectives, and gaps in the literature.

Methods: We conducted a global search of interventions to reduce ambient air pollution, and then conducted a keyword search among these articles to identify literature regarding interventions to reduce individual-initiated burning. We categorized these articles based on whether burning was discussed as an explicit focus or incidental finding and conducted a full-text analysis. We conducted a supplementary review on anthropological aspects of burning behaviors and burning interventions not captured in our review to inform future recommendations.

Results: Ten articles describing interventions for small-scale, individual-initiated burning were identified. Four articles examined burning as an explicit focus and six discussed burning as an incidental finding. China was the country most represented in our review. All but one of the articles discussed emissions-related outcomes, while only one article discussed health outcomes. Four articles explored factors affecting implementation of interventions and regulations, but none included implementation as a primary objective. The supplementary review revealed a large amount of literature about burning in the context of spiritual and agricultural practices. However, less is known about everyday burning behaviors, such as trash burning and household burning, as well as reasons why people burn.

Conclusion: There is a paucity of research that explicitly discusses interventions for small scale, individual-initiated burning practices. Gaps remain in interventions in LMICs most affected by individual-initiated burning, particularly in sub-Saharan Africa. Most of the current literature does not analyze factors affecting effectiveness of interventions and regulations and does not clearly identify reasons why people choose to burn. More research is needed on how to effectively implement interventions to reduce individual-initiated burning, as well as to target key geographic regions and burning sources that continue to be neglected.
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http://dx.doi.org/10.1016/j.envres.2021.110794DOI Listing
April 2021

Vulnerable families and costly formula: a qualitative exploration of infant formula purchasing among peri-urban Peruvian households.

Int Breastfeed J 2021 Jan 19;16(1):11. Epub 2021 Jan 19.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Substantial evidence exists surrounding the health risks of breast milk substitutes (BMS) in place of exclusive breastfeeding among infants < 6 months of age in resource-poor settings. Yet, mothers' experiences of selecting and purchasing BMS brands have not been well studied to date. This qualitative study explored the factors influencing BMS purchasing practices, along with the consequences of those decisions, in peri-urban Lima, Peru.

Methods: We conducted in-depth interviews (IDIs) with 29 mothers who had begun mixed-feeding their infants during the first 6 months of life. Interviews explored participants' reasons for initiating infant formula use and their experiences of selecting, purchasing, and providing BMS to their children. Audio recordings were transcribed, coded, and key themes and illustrative vignettes were identified.

Results: The primary reported reasons for initiating infant formula use included having received a recommendation for infant formula from a healthcare provider, concerns about an infant's weight gain, and the perception of insufficient breast milk. Mothers tended to initially purchase the BMS brand that had been recommended by a doctor, which was often more expensive than the alternatives. The costs of BMS, which escalated as infants grew, often disrupted the household economy and generated significant stress. While some mothers identified alternatives allowing them to continue purchasing the same brand, others chose to switch to less expensive products. Several mothers began to feed their infants follow-on formula or commercial milk, despite their awareness that such practices were not recommended for infants under 6 months of age. The approval of family members and the absence of an infant's immediate adverse reaction influenced mothers' decisions to continue purchasing these products.

Conclusions: The high costs of BMS may deepen existing socio-economic vulnerabilities and generate new risks for infant health. The continued dedication of resources towards breastfeeding education and support is critical, and strategies would benefit from underscoring the long-term financial and health consequences of infant formula use, and from strengthening women's self-efficacy to refuse to initiate infant formula when recommended. In addition, health providers should be trained in counseling to help women to relactate or return to exclusive breastfeeding after cessation.
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http://dx.doi.org/10.1186/s13006-021-00356-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816440PMC
January 2021

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh.

Int J Equity Health 2021 Jan 6;20(1):16. Epub 2021 Jan 6.

Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA.

Background: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.

Methods: The current analysis selected 4 indicators from the WASH Benefits trial- presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.

Results: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (- 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, - 25% (- 35, - 15) Q2: - 34% (- 44, - 23%)] than the wealthiest household [Q5 DID: - 1% (- 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%).

Conclusion: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program.

Trial Registration: WASH Benefits Bangladesh: ClinicalTrials.gov , identifier: NCT01590095 . Date of registration: April 30, 2012 'Retrospectively registered'.
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http://dx.doi.org/10.1186/s12939-020-01353-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789645PMC
January 2021

Longer Residence in the United States is Associated With More Physical Function Limitations in African Immigrant Older Adults.

J Appl Gerontol 2020 Dec 22:733464820977608. Epub 2020 Dec 22.

Johns Hopkins School of Nursing, Baltimore, MD, USA.

Acculturation and racial discrimination have been independently associated with physical function limitations in immigrant and United States (U.S.)-born populations. This study examined the relationships among acculturation, racial discrimination, and physical function limitations in = 165 African immigrant older adults using multiple linear regression. The mean age was 62 years ( = 8 years), and 61% were female. Older adults who resided in the United States for 10 years or more had more physical function limitations compared with those who resided here for less than 10 years ( = -2.62, 95% confidence interval [CI] = [-5.01, -0.23]). Compared to lower discrimination, those with high discrimination had more physical function limitations ( = -2.51, 95% CI = [-4.91, -0.17]), but this was no longer significant after controlling for length of residence and acculturation strategy. Residing in the United States for more than 10 years is associated with poorer physical function. Longitudinal studies with large, diverse samples of African immigrants are needed to confirm these associations.
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http://dx.doi.org/10.1177/0733464820977608DOI Listing
December 2020

Integrating Mental Health into Maternal Health Care in Rural Mali: A Qualitative Study.

J Midwifery Womens Health 2021 03 16;66(2):233-239. Epub 2020 Dec 16.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Introduction: Common perinatal mental disorders are prevalent in low- and middle-income countries. The gap between the need for and availability of mental health services, also known as the mental health treatment gap, is particularly acute for women during the perinatal period in rural Mali. This qualitative study aimed to identify a feasible and acceptable integrated care approach for the provision of maternal mental health care in rural Mali to help narrow the treatment gap and increase access to care.

Methods: From April to June 2016, qualitative data were collected in the Sélingué health district and Bamako, Mali. In-depth interviews were conducted among women, community health workers, midwives, and mental health specialists. Focus group participants included community health workers, midwives, and an obstetric nurse. All data were inductively coded and analyzed using a thematic analysis approach.

Results: Women described several coping strategies to manage their distress, including visiting their parents; confiding in a friend, relative, or community health worker; and participating in women's association groups. Mental health-related stigma was described as being widespread in the community and among health providers. In response to the lack of mental health services, midwives and community health workers supported the feasibility and acceptability of the integration of mental health services into maternal health services. Midwives were discussed as being key providers to conduct mental health screenings and provide initial psychosocial care for women.

Discussion: Integrated maternal and mental health interventions are needed to narrow the gap between the need for and availability of mental health services in rural Mali. Findings from this study underscore the great need for mental health services for women in the perinatal period who reside in rural Mali and that it is both feasible and acceptable to integrate mental health screening and low-level psychosocial care into antenatal care, delivered by midwives.
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http://dx.doi.org/10.1111/jmwh.13184DOI Listing
March 2021

"All I know is that there is a lot of discrimination": Older African immigrants' experiences of discrimination in the United States.

Geriatr Nurs 2021 Jan-Feb;42(1):196-204. Epub 2020 Oct 22.

Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205, United States of America; Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States of America.

Discrimination is implicated in the disproportionate burden of disease and health disparities in racial/ethnic minorities. This qualitative descriptive study explored the experiences of discrimination and its impact on the health of older African immigrants. Semi-structured interviews were conducted with 15 participants. Three main themes and six sub-themes were identified. These included: (1) types of discrimination which were: (a) accent-based, (b) unfair treatment during routine activities, (c) experience with systems; (2) consequences of discrimination; and (3) surviving and thriving with discrimination: (a) "blind eye to it", (b) reacting to it, (c) avoiding it. These themes described common experiences of discrimination, current strategies used to deal with discrimination, and the impact of discrimination on this sample. Health care providers should be aware of discrimination experiences, how to assess for it, and identify when to refer patients to appropriate community resources that include mental health, employment, cultural groups and legal services.
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http://dx.doi.org/10.1016/j.gerinurse.2020.08.002DOI Listing
October 2020

'I worked until my body was broken': an ethnomedical model of chronic pain among North Korean refugee women.

Ethn Health 2020 Nov 15:1-19. Epub 2020 Nov 15.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Objectives: While increasing numbers of North Korean refugees (NKRs) are migrating to South Korea, different understandings of physical pain between NKR patients and the South Korean healthcare providers may create miscommunication and less satisfaction with their care management. To identify strategies to improve care, this study elicits and presents an ethnomedical model of chronic pain among NKR women.

Design: Twenty semi-structured individual interviews were conducted with NKR women with chronic pain living in South Korea. Inductive and deductive thematic analysis was performed on three types of data: interview transcripts, field notes created after each interview, and memos written during the analysis.

Results: Participants reported that pain started after a certain period of resettlement and expressed frustration when there was no definite diagnosis for pain. They identified physical factors (e.g. excessive labor, exposure to violence, and poor diet) as the primary causes, while psychological factors (e.g. loneliness, rumination, and financial burden of sending remittances to North Korea) were viewed as collateral or contributing causes. Several participants indicated emotional discomfort when they were referred to psychiatrists for unceasing pain. Physical treatment (injections, medications, or acupuncture) and providers' sincere attitudes were expectations of care considered capable of addressing both physical and emotional distress.

Conclusions: Findings highlight the need to understand NKR women's ethnomedical model of chronic pain, which is distinct from illness model of healthcare providers. These preliminary findings could be used to improve care strategies based on NKRs' care needs.
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http://dx.doi.org/10.1080/13557858.2020.1841886DOI Listing
November 2020

Residential Greenness Positively Associated with the Cortisol to DHEA Ratio among Urban-Dwelling African American Women at Risk for HIV.

J Urban Health 2020 Nov 9. Epub 2020 Nov 9.

, La Jolla, USA.

As ecosystems that support human health, societies, and civilization change in the era of the Anthropocene, individuals with disproportionate balance of salivary hormones may be at greatest risk of morbidity and mortality. Vulnerable communities, in particular, are overburdened by inequities in features of built environments linked to health disparities. This study examined the cross-sectional association of greenness in the built environment with the ratio of cortisol to dehydroepiandrosterone (DHEA) in an urban-dwelling high-risk community sample of African American women (n = 84, age 18-44 years). Saliva samples, collected across 2 consecutive days, were assayed for cortisol and DHEA. Controlling for sexual violence, perceived stress, education, and income, as well as crime, traffic density, and vacant properties, we observed a significant positive cross-sectional association between greenness and the cortisol to DHEA ratio, (β = 7·5, 95% CI: 0.89, 14.19). The findings highlight environmental influence on stress response at waking when there is the greatest individual variation. Implications for advancing our understanding of the waking ratio of cortisol to DHEA as a potential marker of physiological resilience are discussed.
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http://dx.doi.org/10.1007/s11524-020-00492-0DOI Listing
November 2020

Measuring contraceptive self-efficacy in sub-Saharan Africa: development and validation of the CSESSA scale in Kenya and Nigeria.

Contracept X 2020 9;2:100041. Epub 2020 Oct 9.

Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, 1800 Orleans Street, Room 8527, Baltimore, MD 21287, USA.

Objectives: Contraceptive self-efficacy, a women's belief about her own ability to complete the actions necessary for successful family planning, is a well-documented determinant of contraceptive use. However, there is currently no validated measure appropriate for low-resource settings. We developed and tested a new scale to measure Contraceptive Self-Efficacy among women in sub-Saharan Africa (CSESSA) using samples in Kenya and Nigeria.

Study Design: The CSESSA scale was administered to women in Kenya ( = 314) and Nigeria ( = 414). Reliability and validity were analyzed separately by setting. Validity analysis included assessment of the area under the curve (AUC) to demonstrate predictive capability of CSESSA score for contraceptive use. Logistic regression was employed to test the relationship between CSESSA score and contraceptive use.

Results: Item reduction resulted in 11 items in Kenya ( = 0.90) and 10 items in Nigeria ( = 0.93). Three domains of contraceptive self-efficacy emerged in both settings: (1) husband/partner communication, (2) provider communication and (3) choosing and managing a method. Items related to the first two subscales, but not the third, were identical across settings. The AUC indicated predictive capability as mild in Kenya (AUC = 0.58) and strong in Nigeria (AUC = 0.73). In both settings, CSESSA score was associated with use of a modern contraceptive method at 12 months postpartum.

Conclusions: The CSESSA scale is a reliable and valid measure in two countries. Variation of the third subscale by site indicates that certain scale items may be more relevant in areas of low versus high contraceptive prevalence. Further research should be done to validate this subscale in other contexts.

Implications: This study contributes a reliable, valid measure of contraceptive self-efficacy in two African countries. The CSESSA scale and subscales can be administered in research (for example for evaluation of interventions to increase contraceptive uptake) or in a clinical setting to inform and improve contraceptive counseling.
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http://dx.doi.org/10.1016/j.conx.2020.100041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591732PMC
October 2020

Reported infant feeding practices and contextual influences on breastfeeding: qualitative interviews with women registered to MomConnect in three South African provinces.

Int Breastfeed J 2020 09 14;15(1):81. Epub 2020 Sep 14.

National Department of Health, Pretoria, South Africa.

Background: Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage.

Methods: For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February-March 2018 in South Africa's KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes.

Results: Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media.

Conclusions: Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women's knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women's breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.
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http://dx.doi.org/10.1186/s13006-020-00315-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489212PMC
September 2020

Piloting an acceptable and feasible menstrual hygiene products disposal system in urban and rural schools in Bangladesh.

BMC Public Health 2020 Sep 7;20(1):1366. Epub 2020 Sep 7.

Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 615 N. Wolfe St, Baltimore, MD, 21205, USA.

Background: Access to washroom facilities and a place to dispose of menstrual waste are prerequisites for optimal menstrual hygiene management in schools. Like other low- and middle-income countries, Bangladeshi schools lack facilities for girls to change and dispose of their menstrual absorbents. We explored existing systems for disposing of menstrual absorbent wastes in urban and rural schools of Bangladesh and assessed the feasibility and acceptability of alternative disposal options.

Methods: We explored how girls dispose of their menstrual products, identified girls' preferences and choices for a disposal system and piloted four disposal options in four different schools. We then implemented one preferred option in four additional schools. We explored girls', teachers', and janitors' perspectives and evaluated the acceptability, feasibility, and potential for sustainability of the piloted disposal system.

Results: Barriers to optimal menstrual hygiene management included lack of functional toilets and private locations for changing menstrual products, and limited options for disposal. Girls, teachers, and janitors preferred and ranked the chute disposal system as their first choice, because it has large capacity (765 L), is relatively durable, requires less maintenance, and will take longer time to fill. During implementation of the chute disposal system in four schools, girls, teachers, and janitors reported positive changes in toilet cleanliness and menstrual products disposal resulting from the intervention.

Conclusions: The chute disposal system for menstrual products is a durable option that does not require frequent emptying or regular maintenance, and is accepted by schoolgirls and janitors alike, and can improve conditions for menstrual hygiene management in schools. However, regular supervision, motivation of girls to correctly dispose of their products, and a long-term maintenance and management plan for the system are necessary.
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http://dx.doi.org/10.1186/s12889-020-09413-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487504PMC
September 2020

Predicting Malaria Transmission Dynamics in Dangassa, Mali: A Novel Approach Using Functional Generalized Additive Models.

Int J Environ Res Public Health 2020 08 31;17(17). Epub 2020 Aug 31.

Malaria Research and Training Center, Faculty of Medicine, Pharmacy and Dentistry, University of Sciences, Techniques and Technologies of Bamako, Bamako BP 1805, Mali.

Mali aims to reach the pre-elimination stage of malaria by the next decade. This study used functional regression models to predict the incidence of malaria as a function of past meteorological patterns to better prevent and to act proactively against impending malaria outbreaks. All data were collected over a five-year period (2012-2017) from 1400 persons who sought treatment at Dangassa's community health center. Rainfall, temperature, humidity, and wind speed variables were collected. Functional Generalized Spectral Additive Model (FGSAM), Functional Generalized Linear Model (FGLM), and Functional Generalized Kernel Additive Model (FGKAM) were used to predict malaria incidence as a function of the pattern of meteorological indicators over a continuum of the 18 weeks preceding the week of interest. Their respective outcomes were compared in terms of predictive abilities. The results showed that (1) the highest malaria incidence rate occurred in the village 10 to 12 weeks after we observed a pattern of air humidity levels >65%, combined with two or more consecutive rain episodes and a mean wind speed <1.8 m/s; (2) among the three models, the FGLM obtained the best results in terms of prediction; and (3) FGSAM was shown to be a good compromise between FGLM and FGKAM in terms of flexibility and simplicity. The models showed that some meteorological conditions may provide a basis for detection of future outbreaks of malaria. The models developed in this paper are useful for implementing preventive strategies using past meteorological and past malaria incidence.
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http://dx.doi.org/10.3390/ijerph17176339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7504016PMC
August 2020

Adaptation and Integration of Psychosocial Stimulation, Maternal Mental Health and Nutritional Interventions for Pregnant and Lactating Women in Rural Bangladesh.

Int J Environ Res Public Health 2020 08 27;17(17). Epub 2020 Aug 27.

Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.

Supporting caregivers' mental wellbeing and ability to provide psychosocial stimulation may promote early childhood development. This paper describes the systematic approach of developing an integrated stimulation intervention, identifying the feasibility and challenges faced throughout the period. We developed an integrated curriculum by culturally adapting three interventions (Reach Up, Thinking Healthy, and general nutrition advice) and piloted this curriculum (Mar-April 2017) in courtyard groups sessions and individual home visits with pregnant women ( = 11) and lactating mothers (of children <24 months) ( = 29). We conducted qualitative interviews with the participants ( = 8) and the community health workers who delivered the intervention ( = 2). Most participants reported willingness to attend the sessions if extended for 1 year, and recommended additional visual cues and interactive role-play activities to make the sessions more engaging. Participants and community health workers found it difficult to understand the concept of "unhealthy thoughts" in the curriculum. This component was then revised to include a simplified behavior-focused story. Community health workers reported difficulty balancing the required content of the integrated curriculum but were able to manage after the contents were reduced. The revised intervention is likely feasible to deliver to a group of pregnant and lactating mothers in a low-resource setting.
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http://dx.doi.org/10.3390/ijerph17176233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7503282PMC
August 2020

Formative research to scale up a handwashing with soap and water treatment intervention for household members of diarrhea patients in health facilities in Dhaka, Bangladesh (CHoBI7 program).

BMC Public Health 2020 Jun 1;20(1):831. Epub 2020 Jun 1.

Associate Professor, Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5535, Baltimore, MD, 21205-2103, USA.

Background: During the time a diarrhea patient presents at a health facility, the household members of the patient are at higher risk of developing diarrheal diseases (> 100 times for cholera) than the general population. The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) is a health facility-initiated water treatment and handwashing with soap intervention designed to reduce transmission of diarrheal diseases between patients and their household members. The present research aimed to (1) develop a scalable approach to integrate the CHoBI7 intervention program into services provided at government and private health facilities in Bangladesh; and (2) tailor the intervention program for the household members of all diarrhea patients, irrespective of the etiology of disease.

Methods: We conducted 8 months of formative research, including 60 semi-structured interviews, 2 group discussions, and a pilot study. Thirty-two interviews were conducted with diarrhea patients and their family caregivers, government stakeholders, and health care providers both to explore existing WASH and diarrhea patient care practices in health facilities and to identify considerations for scaling the CHoBI7 program. Fifty-two diarrhea patient households participated in a pilot study of a modified version of the CHoBI7 intervention program for tailoring. Twenty-eight interviews and 2 group discussions were conducted with pilot households to explore experiences with and recommendations for intervention delivery.

Results: The intervention program was modified based on formative research findings. Pilot study participants recognized the benefits of the CHoBI7 intervention program and made suggestions to improve the acceptability and feasibility of the intervention. Modifications included 1) providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility; 2) switching out technology prone to breaks and leaks as well as sourcing plastic technologies from a high-quality, local manufacturer; and 3) including instructions discouraging the non-use or misuse of technologies and supplies. Considerations for scalability include the local availability and marketing of enabling technologies and supplies, staff for program delivery in health facilities, and potential integration into existing government or health promotion programs.

Conclusions: Formative research identified important considerations for the content, delivery, and scalability of the CHoBI7 health facility-initiated WASH intervention program.
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http://dx.doi.org/10.1186/s12889-020-08727-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268342PMC
June 2020

Food Security in Artisanal Mining Communities: An Exploration of Rural Markets in Northern Guinea.

Foods 2020 Apr 10;9(4). Epub 2020 Apr 10.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

The number of people engaged in artisanal and small-scale mining (ASM) has grown rapidly in the past twenty years, but they continue to be an understudied population experiencing high rates of malnutrition, poverty, and food insecurity. This paper explores how characteristics of markets that serve ASM populations facilitate and pose challenges to acquiring a nutritious and sustainable diet. The study sites included eight markets across four mining districts in the Kankan Region in the Republic of Guinea. Market descriptions to capture the structure of village markets, as well as twenty in-depth structured interviews with food vendors at mining site markets were conducted. We identified three forms of market organization based on location and distance from mining sites. Markets located close to mining sites offered fewer fruit and vegetable options, as well as a higher ratio of prepared food options as compared with markets located close to village centers. Vendors were highly responsive to customer needs. Food accessibility and utilization, rather than availability, are critical for food security in non-agricultural rural areas such as mining sites. Future market-based nutrition interventions need to consider the diverse market settings serving ASM communities and leverage the high vendor responsiveness to customer needs.
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http://dx.doi.org/10.3390/foods9040479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231122PMC
April 2020

Interpretation of vulnerability and cumulative disadvantage among unaccompanied adolescent migrants in Greece: A qualitative study.

PLoS Med 2020 03 27;17(3):e1003087. Epub 2020 Mar 27.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Background: In settings of mass displacement, unaccompanied minors (UAMs) are recognized as a vulnerable group and consequently prioritized by relief efforts. This study examines how the interpretation of vulnerability by the national shelter system for male UAMs in Greece shapes their trajectories into adulthood.

Methods And Findings: Between August 2018 and April 2019, key informant interviews were carried out with child protection staff from Greek non-governmental organizations that refer UAMs to specialized children's shelters in Athens to understand how child protection workers interpret vulnerability. In-depth interviews and life history calendars were collected from 44 male migrant youths from Afghanistan, Pakistan, Bangladesh, and Iran who arrived in Greece as UAMs but had since transitioned into adulthood. Analysis of in-depth interviews and life history calendars examined how cumulative disadvantage and engagement with the shelter system altered youths' trajectories into adulthood. Younger adolescents were perceived as more vulnerable and prioritized for shelters over those who were "almost 18" years old. However, a subset of youths who requested shelter at the age of 17 years had experienced prolonged journeys where they spent months or years living on their own in socially isolated environments that excluded them from experiences conducive to adolescent development. The shelter system for UAMs in Greece enabled youths to develop new skills and networks that facilitated integration into society, and transferred them into adult housing when they turned 18 years old so that they could continue developing new skills. Those who were not in shelters by age 18 years could not access adult housing and lost this opportunity. Limitations included possible underrepresentation of homeless youth as well as the inability to capture all nationalities of UAMs in Greece, though the 2 most common nationalities, Afghan and Pakistani, were included.

Conclusions: Due to the way vulnerability was interpreted by the shelter system for UAMs, youths who had the greatest need to learn new skills to facilitate their integration often had the least opportunity to do so. To avoid creating long-lasting disparities between UAMs who are placed in shelters and those who are not, pathways should be developed to allow young adult males to enter accommodation facilities and build skills and networks that facilitate integration. Furthermore, cumulative disadvantages should be taken into account while assessing UAMs' vulnerability. Following UAMs' trajectories into early adulthood was critical for capturing this long-term consequence of the shelter system's interpretation of vulnerability.
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http://dx.doi.org/10.1371/journal.pmed.1003087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7100937PMC
March 2020

Snack food consumption among Bangladeshi children, supplementary data from a large RCT.

Matern Child Nutr 2020 10 20;16(4):e12994. Epub 2020 Mar 20.

Department of Nutrition, University of California Davis, Davis, California.

Childhood obesity has been associated with consumption of energy-dense foods such as caloric beverages and fast foods. Many low- and middle-income countries like Bangladesh are now experiencing a rising problem of noncommunicable diseases along with the long-standing problem of stunting and undernutrition. WASH Benefits Bangladesh was a large community-based cluster randomized controlled trial conducted in rural Bangladesh. Study clusters were randomized into seven arms: single nutrition (N); water (W); sanitation (S); hygiene (H); combined water, sanitation, and hygiene (WSH); WSH and nutrition (N + WSH); and a double sized control (C). Nutrition intervention messages included four promotional components: maternal nutrition, breastfeeding, complementary feeding, and lipid-based nutrient supplements. The World Health Organization infant food frequency questionnaire (24-hr recall and 7-day recall) was administered at Year 1 and Year 2 of intervention. The likelihood of any snack food consumption was significantly lower (odds ratio 0.37: 95% confidence interval [0.28, 0.49]) in the nutrition intervention arms compared to the control arm in Year 2 follow-up. In addition, in the water intervention arm, fewer children (about 50% less) consumed soft drinks, but not the other sugar-sweetened beverages, compared with control in Year 2. There were no other differences between groups. Simple messages about balanced diet and feeding family foods were effective in lowering commercially produced snack food consumption of the young children in low-income rural communities of Bangladesh. Provision of safe water apparently encouraged mothers to reduce offering unhealthy beverages to the young children.
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http://dx.doi.org/10.1111/mcn.12994DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507356PMC
October 2020

Effect of Improved Water Quality, Sanitation, Hygiene and Nutrition Interventions on Respiratory Illness in Young Children in Rural Bangladesh: A Multi-Arm Cluster-Randomized Controlled Trial.

Am J Trop Med Hyg 2020 05;102(5):1124-1130

International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.

Acute respiratory infections cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (S); 3) handwashing promotion (H); 4) combined water, sanitation, and handwashing (WSH); 5) nutrition intervention including lipid-based nutrient supplements; 6) combined WSH plus nutrition (WSHN); or 7) no intervention (control). Masking of participants was not possible. Acute respiratory illness was defined as caregiver-reported persistent cough, panting, wheezing, or difficulty breathing in the past 7 days among index children, those born to enrolled women. We assessed outcomes at 12 and 24 months of intervention using intention to treat. Compared with children in the control group (ARI prevalence, : 8.9%), caregivers of index children reported significantly lower ARI in the water (: 6.3%, prevalence ratio (PR): 0.71; 95% CI: 0.53, 0.96), sanitation (: 6.4%, PR: 0.75, 95% CI: 0.58, 0.96), handwashing (: 6.4%, PR: 0.68, 95% CI: 0.50, 0.93), and the combined WSH+N arms (: 5.9%, PR: 0.67, 95% CI: 0.50, 0.90). Those in the nutrition (: 7.4%, PR: 0.84, 95% CI: 0.63, 1.10) or the WSH arm (: 8.9%, PR: 0.99, 95% CI: 0.76, 1.28) reported similar ARI prevalence compared with control children. Single targeted water, sanitation, and hygiene interventions reduced reported respiratory illness in young children. There was no apparent respiratory health benefit from combining WASH interventions.
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http://dx.doi.org/10.4269/ajtmh.19-0769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204588PMC
May 2020

Small-Scale Livestock Production in Nepal Is Directly Associated with Children's Increased Intakes of Eggs and Dairy, But Not Meat.

Nutrients 2020 Jan 18;12(1). Epub 2020 Jan 18.

Center for Human Nutrition and Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA.

Animal source foods (ASF) provide nutrients essential to child growth and development yet remain infrequently consumed in rural Nepal. Agriculture and nutrition programs aim to increase ASF intake among children through small-scale animal husbandry projects. The relationship between livestock ownership and children's consumption of ASF, however, is not well established. This study examined associations between livestock ownership and the frequency with which Nepali children consume eggs, dairy, and meat. We analyzed longitudinal 7-day food frequency data from sentinel surveillance sites of the Policy and Science of Health, Agriculture and Nutrition (PoSHAN) study. Data consisted of surveys from 485 Nepali farming households conducted twice per year for two years (a total of 1449 surveys). We used negative binomial regression analysis to examine the association between the number of cattle, poultry, and meat animals (small livestock) owned and children's weekly dairy, egg, and meat intakes, respectively, adjusting for household expenditure on each food type, mother's education level, caste/ethnicity, agroecological region, season, and child age and sex. We calculated predicted marginal values based on model estimates. Children consumed dairy 1.4 (95% CI 1.1-2.0), 2.3 (1.7-3.0) and 3.0 (2.1-4.2) more times per week in households owning 1, 2-4 and >4 cattle, respectively, compared to children in households without cattle. Children consumed eggs 2.8 (2.1-3.7) more times per week in households owning 1 or 2 chickens compared to children in households without chickens. Child intake of meat was higher only in households owning more than seven meat animals. Children's intakes of dairy, eggs, and meat rose with household expenditure on these foods. Small-scale animal production may be an effective strategy for increasing children's consumption of eggs and dairy, but not meat. Increasing household ability to access ASF via purchasing appears to be an important approach for raising children's intakes of all three food types.
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http://dx.doi.org/10.3390/nu12010252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019975PMC
January 2020

Moving towards transformational WASH - Authors' reply.

Lancet Glob Health 2019 11;7(11):e1494-e1495

Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA. Electronic address:

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http://dx.doi.org/10.1016/S2214-109X(19)30401-2DOI Listing
November 2019

Turmeric means "yellow" in Bengali: Lead chromate pigments added to turmeric threaten public health across Bangladesh.

Environ Res 2019 12 6;179(Pt A):108722. Epub 2019 Sep 6.

Stanford Woods Institute for the Environment, Stanford University, Stanford, CA, USA; Stanford Center for Innovation in Global Health, Stanford University, Stanford, CA, USA.

Adulteration is a growing food safety concern worldwide. Previous studies have implicated turmeric as a source of lead (Pb) exposure due to the addition of lead chromate (PbCrO), a yellow pigment used to enhance brightness. We aimed to assess the practice of adding yellow pigments to turmeric and producer- consumer- and regulatory-factors affecting this practice across the supply chain in Bangladesh. We identified and visited the nine major turmeric-producing districts of Bangladesh as well as two districts with minimal turmeric production. In each district, we conducted semi-structured interviews and informal observations with individuals involved in the production, consumption, and regulation of turmeric. We explored perceptions of and preferences for turmeric quality. We collected samples of yellow pigments and turmeric from the most-frequented wholesale and retail markets. We collected samples of turmeric, pigments, dust, and soil from turmeric polishing mills to assess evidence of adulteration. Interviews were analyzed through an inductive, thematic coding process, with attention focused on perceptions of and preferences for turmeric quality. Samples were analyzed for Pb and chromium (Cr) concentrations via inductively coupled plasma mass spectrometry and x-ray fluorescence. In total, we interviewed 152 individuals from across the supply chain and collected 524 samples of turmeric, pigments, dust, and soil (Table S3, Table S4). Turmeric Pb and Cr concentrations were highest in Dhaka and Munshiganj districts, with maximum turmeric powder Pb concentrations of 1152 μg/g, compared to 690 μg/g in the 9 major turmeric-producing districts. We found evidence of PbCrO-based yellow pigment adulteration in 7 of the 9 major turmeric-producing districts. Soil samples from polishing mills contained a maximum of 4257 μg/g Pb and yellow pigments contained 2-10% Pb by weight with an average Pb:Cr molar ratio of 1.3. Turmeric wholesalers reported that the practice of adding yellow pigments to dried turmeric root during polishing began more than 30 years ago and continues today, primarily driven by consumer preferences for colorful yellow curries. Farmers stated that merchants are able to sell otherwise poor-quality roots and increase their profits by asking polishers to adulterate with yellow pigments. Adulterating turmeric with lead chromate poses significant risks to human health and development. The results from this study indicate that PbCrO is being added to turmeric by polishers, who are unaware of its neurotoxic effects, in order to satisfy wholesalers who are driven by consumer demand for yellow roots. We recommend immediate intervention that engages turmeric producers and consumers to address this public health crisis and ensure a future with Pb-free turmeric.
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http://dx.doi.org/10.1016/j.envres.2019.108722DOI Listing
December 2019

Piloting a Shared Source Water Treatment Intervention among Elementary Schools in Bangladesh.

Am J Trop Med Hyg 2019 11;101(5):984-993

Stanford University, Stanford, California.

Hundreds of thousands of children continue to die each year from diarrhea. We piloted a low-cost liquid chlorine point-of-use (POU) water treatment among elementary school children in Bangladesh. We began the 1-month intervention in four schools (two urban and two rural) by introducing POU drinking water hardware and behavior change communication. We trained teachers to deliver sessions encouraging students to drink chlorinated water from their own small plastic bottles to avoid disease transmission. We used cue cards and flip charts as visual aids. We evaluated the acceptability, feasibility, and potential for sustainability after 1 month and after 14 months of the intervention. During 1-month follow-up, among 141 drinking events observed, 141 students (100%) drank chlorinated water. In 93 or 66% of events, students used their own bottles, and in 43 (30%) of the events, they used common cups or hands washed before drinking. During the 14-month follow-up, we observed 732 drinking events. In 653 of 732 events (89%), students drank chlorinated water; in 78 events (11%), they consumed water from untreated drinking water sources. Among those who consumed chlorinated water, 20% (131/653) used their own bottles to drink water, 72% (467/653) used common cups, and 8% (55/653) used both hands to drink water. Most stated that they drank chlorinated water because it is safe, it has health benefits, and treatment reduces germs. Introduction of specific hardware, weekly hygiene sessions, and education materials enabled schools to treat water at POU and students to consume treated water.
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http://dx.doi.org/10.4269/ajtmh.18-0984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6838573PMC
November 2019